According to a 2012 survey by the American Heart Association, most women believed that breast cancer was the #1 killer of women. Katie Twomley, MD, Wake Forest Baptist Health Lexington Medical Center, and Sandy Tysinger, MSN, RN, PCCN, Wake Forest Baptist Health, present on the need to educate women about standard heart disease risks and risks specific to females. They also discuss heart attack signs and symptoms that are unique to women, diagnostic differences between men and women, and gender bias that occurs in the treatment of heart disease.
View Doctor Profile KATIE TWOMLEY: All right, obviously I'm talking about women's heart health. We know that is still the number one killer of women in the United States. It actually kills five times more women than breast cancer, which is surprising to a lot of women that I tell that to in my clinic. I have a little image here that is actually from 2002. It's a bit outdated. In this image heart disease is actually eight times more likely to kill women than breast cancer. If you do notice though, stroke is the number two killer in women, and still is. So another cardiovascular cause of death-- the top two killers in women. That's why we're here today talking. If you notice in the slide also, stroke along with heart failure are more common in women than men. Black women have an even higher risk of heart failure and stroke than white women. There are some good news, though. There's been a 60% decline in the rate of death from heart disease over the last 35 years. This might be partly due to increased awareness in women, also increased awareness in physicians and health care providers for better risk factor management overall. But we have to attribute some of this risk-- some of this reduction in risk of death to advances in medicine. In the slide, you can see that both women and men have had a similar decline in their death rate from cardiovascular disease. However, women comparatively still die more from heart disease than men. SANDY TYSINGER: OK. So in 2005, the Journal of Critical Care Nursing did a survey, and they found that 57% of women could identify heart disease as the number one killer. So that's pretty good, more than half of them were more aware of what's going on in our lives. However, in 2012, the American Heart Association did a survey, and they broke it out into different cultures. So 56% of Caucasian women could identify heart disease as the number one killer. But interesting, the disparity between African American women and Hispanic women-- 36% of African American women could identify heart disease as the number one killer, and only 34% of Hispanic women. Why is that? Why do you think that is? What do we see? We see a lot of things out there for breast cancer. They still identify breast cancer as the number one killer. How many times do you turn your TV on and see a fundraiser-- the Susan B Komen foundation, which is a great foundation. I'm not taking anything away from it. But what do you see? There's a lot-- do you agree? There's a lot of publicity out there. Pink shirts, pink ribbons, pink ties, pink everything. It's great. It's wonderful. It's brought recognition to the disease, but unfortunately for women in heart disease, we don't quite have as much. So our education is not quite where it should be. KATIE TWOMLEY: So we know that women are at risk for heart disease death and cardiovascular disease. And as health care providers, we are all very aware of the standard risk factors for heart disease. And the general population is also loosely aware of these risk factors for heart disease, including diabetes, vascular disease like stroke or history of stroke or peripheral artery disease, high blood pressure, high cholesterol, tobacco dependence, genetics, advancing age, et cetera. There are some other less known risk factors and perhaps, less attended to risk factors that we should be aware of. As health care providers, we're aware that our patients' lifestyles greatly affect their overall health. So things like obesity, sedentary lifestyle, poor diet, high stress environments-- those contribute to all sorts of illnesses, not just heart disease. Our patients, however, aren't quite as aware how their lifestyles are putting them at risk. I think that educating patients about that is a very important part of how we can prevent heart disease onset. There are some nonstandard risk factors that even some health care providers are not aware of. Pregnancy complications can lead to future onset of cardiovascular disease in patients and women, obviously. I ask all my women about their pregnancies and whether they had pregnancy induced hypertension, preeclampsia, or eclampsia. All those things actually predict a future onset of cardiovascular disease. Also in women, autoimmune collagen-vascular disorders, which tend to be more common than in men, like lupus and rheumatoid arthritis, can predict cardiovascular disease onset. Both by the fact that they cause vascular inflammation, but also because long-term steroid use can lead to the progression of coronary plaque. SANDY TYSINGER: So like Katie said, there's extra complications. So not only do women have to worry about hypertension, obesity, smoking-- we now have later predictions. So if you suffered from preeclampsia or gestational diabetes these things can manifest 10 to 20 years later-- these risk factors 10 to 20 years later. So that's kind of scary for those of us-- not me, please-- those of you who are in childbearing age that do have children and you had suffered from that. You now have two more increased risk factors. And remember, you just don't add your risk factors, one and one, they really multiply at the more risk factors you have. So we've got to think about, how do we take care of ourselves while we're pregnant? KATIE TWOMLEY: The Framingham risk score is a tool used by many health care providers to look at cardiovascular disease risk in the general population. Unfortunately, the Framingham risk score was also based off of a longitudinal data in men, primarily. So it is less predictive in women. We know that women have onset of cardiovascular disease, an average, 10 to even 20 years after men. So using a Framingham risk score, which technically gives you a 10 year risk prediction, isn't wise in women. You can look at a woman in her 40s to try to determine her risk, and she'll turn out to be low risk. However, her lifetime risk is actually quite high. I personally do not use the Framingham risk score in my risk prediction for women. As we mentioned, it doesn't include the kind of things that we talked about-- pregnancy induced hypertension, preeclampsia-- it doesn't look at other risk factors for women that are unique to women. So once we realize that we're at risk, how as women can we try to prevent cardiovascular disease onset, besides the general therapies that our physician or health care provider's going to give us? Well, the AHA looked at research on various different prevention modalities. And this is what they came up with in terms of recommendations. Of course, maintaining a healthy weight. A lot of us try very hard to do that. A lot of our patients fail at doing that. Physical activity. They say at least five days a week. Generally, they're talking about cardiovascular activity for 30 minutes a day. Healthy diet. They specifically speak of the DASH diet. We still support aspirin after 65 years of age in women if you have risk for cardiovascular disease. That has been controversial. But the AHA still does support it. It may be wise to have your patients start even earlier if they're at very high risk. Estrogen remains unknown. Now, there's a lot of controversy after the WHI trials. In general, we still don't suggest using postmenopausal estrogen supplementation for cardiovascular disease risk reduction. In fact, if you're taking hormonal supplements after five years postmenopause, they become detrimental as they can be a procoagulant. SANDY TYSINGER: OK, so we all know the traditional textbook symptoms of an MI or a heart attack. Chest pain, chest tightness, an elephant sitting on my chest, I have a belt around my chest or jaw pain, there's nausea, vomiting, diaphoresis, left arm pain. But don't let those symptoms fool you. In women, we present differently. So our symptoms we can present more vague. And as a past CCU nurse, there was a lot of times I saw patients who didn't present with those. The women said, I was just more tired than usual. But how many times do we all go home and say, I'm so tired. Do we not say it? We say when we get up and go to work. I'm tired. We say it at lunchtime. I'm tired. So do we pay attention to that, I'm tired? No, we don't. We don't listen to it. But it can be a sign and symptom, along with headaches. Sometimes headaches are an adjunct symptom for women for MIs. It is unusual, but it can happen. Now, I'm not saying we can't have our textbook symptoms. So we can, but we also present very differently. We don't recognize it right away. We don't present, like I said, with textbook. So we have to really pay attention to what's going on with our signs and or symptoms. So we have difficulty. We have difficulty recognizing this in our ourselves, so if we have difficulty, our provider probably has as much difficulty too. And we don't act on it. Why don't we act on our signs and symptoms? We're too busy, aren't we? We're way too busy. We all work, many of us have families, if you don't have children you may have other families you're caring for, some of us are in school, some of us have outside influences. We are way too busy. We don't have time for this. And why would I be having a heart attack? I'm too young and I'm too healthy. And yet, we've seen women in their late 30s and early 40s with heart attacks who never could believe that they've had a heart attack because they're too young. Aren't heart attacks for those older women? They're not for women in their 40s. So again, it goes back to our lifestyle. What did we do beforehand? And women wait. We're not going to go to hospital. We're not going to seek treatment. Why do we wait? Because we don't want to bother anybody. It's a typical woman instinct. How many of you ever say, I hate to bother you, but could you help me with something? We said that all the time, don't we? We don't want to draw attention to ourselves. We don't want to complain. And we don't want to be the one sick. We always take care of other people, right? We have to take care of our families. We have to take care of our animals. We have to take care of our job. Who's going to do all this for us? So we don't want to complain. We have to just drudge on. It will go away. How many of you have had aches and pains and things, and you think oh, it will go away? I'll just go take some Motrin, some aspirin, something, I'll go to bed. It'll go away. Well, signs and symptoms of heart attacks really don't go away. They come back, and they manifest themselves later on. So we need not to wait anymore. We need to not be-- we need to be a little more self-centered, and take care of ourselves and not wait anymore. KATIE TWOMLEY: When a woman finally presents with signs or symptoms of cardiovascular disease, we diagnose her the same way we diagnose men. We use the same tests. We have the same lab cutoffs. We use the same cardiac cath criteria for what's a significant lesion. A lot of these data we've talked about are based on trials long ago that were primarily in men. But modern research has started to equally distribute men and women in these trials. And it turns out that actually, that is the right to do. There is not a significant difference in a troponin elevation for a woman versus a man, and we can use those values. In the cath lab, there's not a difference in what's obstructed in a woman and a man. And we have modern techniques now to look at flow across lesions to know that a visual assessment, even if it was biased by a physician, can often be determined whether it was significant or not with actual hard data. We do know there are some differences in the results that we get in testing. So men tend to have more elevations in troponin that are intermediate. If you're in health care you know that 0.06. What do you do with that? Often men come in when asymptomatic or with a non cardiac complaint, more often because they have larger hearts and there's more muscle mass there. We also know that more women get diagnosed with small vessel disease, or what-- at some point-- was call syndrome X. You have chest pain. You have some objective evidence of ischemia, but you have normal coronary arteries on cardic catheterization. Furthermore, in echocardiography, the measurements that we have as our norm-- for LV size, wall thickness, et cetera-- are mostly based on a male population. So women would tend to fit in the lower end of that. This may lead to under diagnosis of conditions in women like LBH or LB delimitation, which are sometimes significant in looking at when someone needs to go for valve surgery. So we do need to pay attention to women's heart size when we're interpreting these data. Also, exercise EKG testing is less sensitive and less specific in women because we tend to have more nonspecific STT wave changes on our baseline EKG, as well as with exercise. Often, I try to add echo to make that more accurate. Insurance companies are making that a difficult thing though, because ordering echo stress almost always calls it a [INAUDIBLE]. One thing I found interesting in my research was that chronotropic incompetence on a stress test is actually more prognostic in women for future cardiovascular events or for underlying disease than men. So chronotropic incompetence, if you don't know, is just the ability to elevate your heart rate with exercise. Keep in mind, if you're looking at these tests that if someone's on a beta blocker or a calcium channel blocker, that's going to make the test falsely abnormal. SANDY TYSINGER: OK, so we have women who cannot recognizer their signs and symptoms. Then we have women who delay treatment. So what happens when they delay treatment? They end up with worse problems. They're ischemia is worst. They end up with more damage to their hearts. So now we have women who tend to refuse testing. Through research, a lot of women refuse testing. They don't want to go for testing. Why don't they want to go? What are they worried about? They're worried about their families. Who's going to pick up the kids? How many of you have to pick up your kids or watch older elderly parents? You're responsible for them. Who's going to feed the animals? Now, you know that nobody can take care of our families like we can take care of our families. They can't even take care of themselves as well as we think we can take care of them. Isn't that right? We also worry about our jobs. And then the last thing is what if they find something? We get scared. We don't want to know if they're going to find something. We don't want to know because we're worried about our families. Women tend to be, not always, but we tend to be the caregivers. We feel like we have to care for the kids. We care for the husband. We wash the clothes. We clean the house. Now, I will say, in my house, my husband does every bit of the laundry, 100% of the laundry. But I do all the ironing, and yes, I still iron. But in our house, it's different. A lot of people, especially if you have children or caring for elderly parents, you don't feel like you have the time to go for testing. Most women will refuse testing, more so than men. Another thing is we don't want to recognize our signs and symptoms. We don't want to go for treatment. So we end up with more problems. And now, we don't want to even enroll in preventive studies. We don't have the time. A lot of people are-- that's our excuse anyway. And it's true, it is our excuse. We feel like, again, we have too many other things going on. We have too many outside influences. And generally, women tend not to want to have the focus on ourselves. Isn't that right? We tend to want to care for everybody else, make sure they're healthy, are you not feeling well to your child or you husband-- we need to take you to your physician. We need to take you to make sure you're OK. But we don't do it for ourselves. We tend not to want to take care of ourselves. And we need to get a little more selfish if we need to, a little more self-centered in the point of taking care of ourselves. We take care of everyone else, but we don't take care. And those nurses that are in the audience, you come to work sick, because you're going to take care of your patients. But you're really not taking care of your patients if you're coming to work sick. You're not even taking care of yourself. Now, you've hurt your peers because you're coming to work sick and you're spreading it everywhere. But we tend to have a little tiny bit of martyrism in us, and we tend to want to care for everybody else before we want to care for ourselves. So in 2013, Emory University in Atlanta did a study they called the Mims study, which stands for Myocardial Ischemia related to Mental Stress. And they wanted to look at how stress impacts men and women. Does it impact them differently? And does it impact-- how does it impact the relationship of cardiovascular disease? So the one thing they did find out is stress does impact women different than it does men. OK, so it was not a very large study. It only had 98 participants. It was equally divided, 49 men and 49 women. And they tend to go to the younger side, and they did ages 38 to 59. And the way they performed the study was they had each participant think of an emotional subject in their life or an emotional time-- could have been a death of a loved one. Some women chose-- they had been sexually abused. They relived that time. Some men chose a death of a loved one as well or a traumatic event in their life. And then they made them do public speaking. And they videotaped them. They had to speak on the subject that was very emotional to them, and their vital signs were monitored throughout the entire talk. Immediately following the talk, they had a cardiac MRI to look at their cardiovascular system. And then on another day, they were put under standard exercise stress test. If the participant could not do a standard exercise stress test, it was chemically induced. They did find that mental stress affected women ages 50 and younger more so than men. 56% of the women had some type of cardio ischemia, as compared to 25% of men. That's a big difference. We really take it to heart. The other thing they took some factors in consideration is women who are age 50 or younger tend not to be as financially stable as older women and even as men. So say they consider that a risk factor. But it really did show that stress does play a part on your cardiovascular system-- on your heart attacks. It can help, or it can add a risk factor to it. So it still leaves a lot of questions with that study. It was not run very long, and as you can see, it was a very small group. But what about different cultures? Does it affect them differently? What about different times in women's life? Like I said, it was not a long study, and it was not a very large study. But it still leaves us to want to think more about what happens later on. What about those that are over 50 or over 55? And there's a lot more research that needs to be done on mental stress and heart attacks. KATIE TWOMLEY: OK, so if you're a general health care provider or a cardiologist, you've probably noticed this trend in heart failure with preserved ejection fraction, or formally known as diastolic heart failure. And I placed this slide here because I don't think we completely understand why we develop this heart failure with preserved ejection fraction so prominently, especially in women. Perhaps, that's related to some subclinical ischemia over a lifetime, and happening more in women than in men, as Sandy just talked about. But in my practice, certainly, I'm seeing a lot of women who come in with heart failure symptoms, sometimes quite profound, that have a preserved ejection fraction. There's one study here that I've put up that actually shows a 60-40 kind of split. So 60% percent of men with heart failure tend to have systolic disfunction versus diastolic. Whereas, 60% of women have diastolic versus systolic. I have a patient who even has been admitted every month for at least 7 days for IV diuresis and she has a completely normal ejection fraction. So this is something that we need to pay more attention to, and it is very profound in women. Unfortunately, despite all that we have learned and all of the awareness that we've risen in heart disease care for women, we still have a gender bias in our treatment. So even in the last, say, 15 years, studies have shown that women are less likely to get guideline anticoagulant therapy when they show up with acute coronary syndrome. In the past, this was thought to be because physicians were scared-- lower weight, smaller size-- are we going to harm these women by giving them high powered anticoagulants? But we've shown that the benefit is the same for men and women, regardless of body size. Less women also go to cath lab if they come in with a STEMI or a non STEMI. So in the Swedeheart study, they showed an 11% less likely to go to the cath lab if you are a woman versus a man when you come in with an actual heart attack. Our mortality remains higher in women, both in hospital and at one year post discharge. So another registry-- the Paris Registry found a similar result. The span of the time when we change from fibrinolytics to primary PCI, so that's why you have a very complicated graph. But the bottom line is about 10%-- so women are 10% less likely to go to the cath lab and get revascularization when they come in with an actual myocardial infarction. This likely leads to some of our increased mortality at one year. There's also a gender bias at discharge. Women are 20% less likely to get guideline recommended medicines at discharge after a heart attack. And let me remind you, that even in primary prevention, we are still less aggressive in women in terms of respect and management. SANDY TYSINGER: OK, so what do we do now? We finally get a woman to recognize that she might be having the signs and symptoms of a heart attack. We finally convince her she may need to seek treatment. We finally get her to agree to have treatment. Well, what do we do now? Do you all recognize a theme here? There's a pattern going on with us. What do we do now? So these are standard advice that we asked folks to do. Stop smoking-- easier said than done. If anyone here is an ex smoker or a smoker and has probably tried to quit, it is not easy. And I'm speaking from personal experience. I quit 20 years ago, and it was probably one of the hardest things I've ever done. And my husband didn't want to be around me for about six weeks. I don't think anybody did. It is very tough to do. But the benefits, we know, outweigh it. It is very hard to get someone to admit they need to quit and to really work through it. So that's where we really need to work with these folks who are so addicted to it. What can we do to help them? 30 minutes of physical activity-- of cardiovascular activity. Now, that doesn't mean chasing after the kids, chasing after the dog, running up and down-- those of us who work at Wake Forest, running up and down the halls-- that's not physical activity. It doesn't count. I don't care what your phone says on your heart rate, if you've done your 10,000 steps or not, you have not done it. So you need to make the time to get on a treadmill, walk outside, find a way to do 30 minutes of activity. If that means on your lunch break, and I know some people are saying, lunch break? Lunch break? But if that means climbing up and down the stairs, get doing some continuous 30 minutes of activity for yourself. Take the time. You are worth it. Eat a healthy diet. I know we've talked-- Katie talked about the DASH diet. There's a Mediterranean diet. There is no diet that's one size fits all, and there's no clothes that one size fits all. But there is no diet-- you and your loved ones and your patients have to find a diet that works for them, whether it be Weight Watchers, the Mediterranean diet, the DASH diet, counting calories, counting back, counting carbs-- whatever works, or a combination of those, whatever works. Now, that doesn't mean you can never eat a piece of cake again, or chocolate or ice cream, it means we have to teach our folks and ourselves how to eat it in moderation. If you want some ice cream that doesn't mean you get to eat the whole container. It just means you get to have a little bit of it. And maintaining your healthy weight. And we're not talking Barbie doll here. There is no such thing as a Barbie Doll weight. Men, if you want us to look like Barbie Doll, then you need to look like Ken or GI Joe. And I don't see that happening. And so you need to maintain a healthy weight. That doesn't mean stick skinny. And I know that we all think of-- when you think of a healthy weight, women, we tend to think more along the lines of someone this big. That's not necessarily a healthy weight. So we need to look at healthy weight, eating healthy, and watching what we eat. But then again, treating yourself. If it means having a piece of candy like there is on the table, that's fine. Just pay attention to what you're eating. It's the same thing we tell our heart patients. If you're going to eat something bad, what do you do to prevent yourself from coming in the hospital? Same thing for us. Women, we need to listen to our bodies. We don't listen to it very well. We ignore our aches and our pains and those things that are abnormal. We do it all the time, but we need to listen to it, and we need to take the time to seek treatment. If you have cardiovascular disease, and you're a candidate to enroll in cardiac rehab, you need to enroll-- or your mother or your grandmother or your sister or whomever. Get them to enroll. Again, we need to follow up with their medications-- aces, our beta blocker, statin therapies, aspirin-- whatever is prescribed for you. Through my experience, dealing with women who have had heart attacks, a lot of times they'll say, I don't have time to take this medication. Is that sounding really familiar to a lot of you? I can't take this right now. It may not make me feel very well. Sometimes beta blockers make us feel a little bad in the beginning when we start taking them. But we do have the time, and sometimes that means we have to hit our patients and our loved ones where they'll listen, like their heart strings. And I will tell this story. I begged and begged and begged my mother to quit smoking. I could never get her to quit smoking, so she never watched her grandchildren grow up. And she never got to see her great grandchild, and there is one grandchild she never got to see because I couldn't get her to be a compliant heart patient. So we really need to hit them where it counts. By the time I really got to get my mom to listen to it, it was really too late by that time. So we really, really do need to make them hear us and what we have to say. What can we do? Cardiology has more research than any other sub specialty. But yet, there's not a lot of women involved in this research. Why is it? It's been the theme of this whole thing. We don't want to take the time to participate because we keep thinking we don't have the time. And I know we're all busy, and if you have children, you are busy. But it's for your children's life, it's for their better health later on, for us to take the time. So get involved. You get involved. You get your mother involved, your grandmother involved, brothers or sisters-- not brothers-- sisters involved, aunts and uncles and cousins. It's time for us to speak up and for women to be involved, and for us to be out there as much as the Susan B Komen foundation, which again, is a great foundation. But we need to be involved, and we need to show them you need to hear us. You need to listen to us.